New perspectives—approaches to medical education at four new UK medical schools
http://www.100md.com
《英国医生杂志》
1 School of Medicine Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, 2 Hull York Medical School, University of York Communications Office, Heslington, York YO10 5DD, 3 Peninsula Medical School, Plymouth PL6 8BX, 4 Brighton and Sussex Medical School, Brighton BN1 9PH
Correspondence to: A Howe amanda.howe@uea.ac.uk
With the expansion in UK medical student numbers, four new medical schools have been established. The authors, all senior faculty members at these new schools at the time of writing, discuss how much the schools have in common in their approaches to medical education
To create more UK doctors, the government has funded an increase in medical student numbers of 57% (from 3749 to 5894)1 between 1998 and 2005. This has been done by increasing student places at existing medical schools; creating shortened programmes open to science graduates; "twinning" arrangements, which host an existing curriculum at a new site; and four entirely new schools (table 1). Through reflection on our experiences and the literature evidence, we examine to what extent these new schools have a common vision and approach to undergraduate medical education, and we discuss the rationale for and likely outcomes of these new ventures.
Table 1 Demographics of the four new UK medical schools
Key perspectives
A key aspect of a medical school's ideology is its approach to the curriculum. The UK accrediting and registering body for medicine, the General Medical Council, has for the past decade called for reforms in medical education2 and recommended courses that integrate teaching of basic sciences (anatomy, biochemistry) with clinical and social sciences, make use of community as well as hospital healthcare settings, increase overall patient contact, and provide greater student choice. New courses are likely to encourage learning methods that directly link new knowledge to patient care,3 modernise approaches to basic science (in particular anatomy4), increase emphasis on appropriate consultation skills5 and attitudinal learning,6 and promote a more humane and supportive learning environment.7
New schools also have the opportunity to take innovative approaches to selecting candidates for medical education and to the assessments that underpin the direction of student learning. How do the four new medical schools deal with these issues?
Student selection and admissions policies
The new medical schools are funded for UK and European Union applicants, and their approaches have been influenced by the "widening access" debate.8 9 They have reconsidered what constitutes necessary prior academic attainment, and they attempt to attract good candidates regardless of age and sociodemographic and school background. Interestingly, although all the new schools offer a full five year undergraduate entry course with no reduction for those who already hold a first degree, between 20% and 60% of their first cohorts have not come directly from secondary school.
All the schools claim to use selection procedures for applicants in which academic criteria are only one hurdle in the process, standardised interviews are the norm, and part of the selection rests on non-academic criteria. All have local access links and programmes to encourage applicants from non-traditional backgrounds (for example, 15% of the intake at the University of East Anglia are from access schemes whereby students from non-traditional backgrounds can do a foundation year of science preparation). The academic performance of applicants who are not coming directly from school is assessed in a variety of ways, with the Peninsula Medical School trialling the GAMSAT (graduate Australian medical schools admissions test)10 as a screening tool. Table 2 gives further details of the selection procedures.
Table 2 Admissions requirements and selection methods of the four new UK medical schools
Curriculum design
Integration
All the new schools integrate student learning by focusing on patients throughout the course. Their curriculums show no traditional divide between clinical and non-clinical phases, nor between basic and applied science. They structure learning around desired outcomes11 and systematically rehearse clinical and technical skills through simulated and supervised "near life" situations. They aim to reduce apprenticeship "tag along with me" learning, which risks wide variation in student opportunities.
All the schools provide a structured learning approach within a "spiral" curriculum (where what the student has already seen and done is explicit, and can be built on)12; this is especially valuable when learning is based on more than one campus (such as with Peninsula Medical School and Hull York Medical School) and at dispersed clinical sites. However, there are considerable differences of local detail, with each school having particular innovations in curriculum design (see table 3). These innovations may be moderated as the GMC assesses each school during its development.
Table 3 Curriculum features of the four new UK medical schools
Students in a practical skills session
Student selected modules
For students to acquire critical appraisal and research skills, the four schools have adopted repeated use throughout the course of what the GMC called student selected modules. These occupy about 30% of course time and draw on the social sciences and humanities as well as professional fields such as law and health economics. In these modules, students encounter methods and assessment modalities similar to those used in postgraduate education—such as peer presentations. All courses include a summatively assessed research project for senior students.
The options of non-clinical topics (such as humanities at University of East Anglia, Brighton and Sussex Medical School, and Hull York Medical School and community studies at Peninsula Medical School) show how these schools aim to broaden students' minds and train them for flexible application of new knowledge and perspectives to medical practice. Process goals are also embraced: Hull York Medical School uses a "market" model for students to choose their modules, to demonstrate economic principles, in line with its theme of "managing resources for quality and efficiency"—thus showing students the constraints of reliance on a "provider" market.
Fitness for purpose
Without historical constraints, the schools have designed their curriculums with the aim of creating junior doctors fit for the purpose of working as part of multidisciplinary teams that include the patients. Early patient contact, systematic consultation skills linked to clinical practice, and group learning settings are used to emphasise the responsibilities of the students towards others. Student progress is assessed on attitudinal as well as intellectual progress, thus ensuring that fitness to practise is a formative curricular goal, rather than a retrospective judgment, and enabling early diagnosis and intervention in areas of weakness (see table 4). The development of mechanisms to identify and act on concerns about fitness to practise is likely to provide other institutions with some valuable lessons.
Table 4 Methods of assessing fitness to practise in the four new UK medical schools
Learning methods and assessment
New approaches to life sciences
The basic life sciences are radically altered both in amount and approach, with dissection and laboratory work being replaced in three of the four schools by prosection (pre-dissected material displayed for students to study, examine, and touch) and use of sophisticated models and computerised imaging. The schools are most diverse in this regard, expressing their individuality and preferred philosophies through such issues as anatomy teaching, with Peninsula Medical School not using cadavers at all whereas Brighton and Sussex Medical School includes dissection throughout the course.
Patient focus is retained in theoretical learning through the use of a range of approaches to problem based learning13—"virtual patients whose problems unfold over time" (Hull York Medical School); a life cycle model tracking the stages of life through both normal and abnormal function (Peninsula Medical School); interdisciplinary clinical symposia (Brighton and Sussex Medical School); all within a systematically planned curriculum based on common clinical presentations (University of East Anglia) (see table 3).
Students engaged in small group learning
Information technology for better communication and integration
All four schools use electronic curriculum programmes ("Blackboard" or "studentcentral") to underpin and coordinate their courses. These allow rapid access to information and quick turnaround of evaluation and messaging, and allow all tutors, assessors, and students at any site to look at the curricular context of their own particular contribution. These managed learning environments form a strong backbone to self directed and e-learning.
Clinical emphasis
All the schools have adopted early contact with patients, supported by large numbers of clinical (NHS) staff as tutors in both campus based teaching and clinical placements. Although the overall time commitment to clinical placements is probably no greater than in other medical schools, they seem to be organised differently. The principle is to base learning on the patient perspective, rather than by specialty. In Hull York Medical School clinical placements, from year 1 to year 4, are fully matched to the specific systems being taught. Peninsula Medical School plans to run placements in years 3 and 4 as "pathways of care" which cross over medical specialties, and University of East Anglia uses large group teaching in general practice that matches patient contact with the "case of the week" rather than opportunistic learning. Introducing new approaches to student learning into a heavily burdened health service is a challenge for the new schools, and the feasibility of such innovations will be judged over time.
Assessment
Under the close scrutiny of panels of visitors from the GMC's Education Committee, each school has developed rigorous procedures to assess students' knowledge, skills, attitudes, and fitness to practise. Formative assessment is generally used to enable students to appreciate their progress, while summative tests ensure that only those who are performing adequately can progress to the next stage of the course or to their preregistration year. Peninsula Medical School has adopted a progress test (run four times a year) for its major summative assessment of applied medical knowledge.14 The objective structured clinical (and practical) examination (OSCE or OSCPE) is commonly used to assess clinical skills; projects and presentations are used to assess other academic ability; and portfolios of evidence from students and tutors reveal attitudes and behaviour. Peer and tutor feedback and reflection on experiential learning help students to compile a summatively assessed "portfolio report." The time needed to perform and validate such detailed, multi-faceted assessments may prove challenging as student numbers increase over the first five years, and more so if further expansion occurs.
The wider academic context
There is considerable tension between teaching and research roles in most universities,15 and this is particularly acute for the new schools—where staff numbers are still building up, there are major educational and organisational challenges in setting up the new courses, and the research units have no institutional track record. Peninsula Medical School has developed research institutions rather than traditional clinical academic departments as the main "home" for its staff, sending a strong message about the value of education in a research-rich environment. Hull York Medical School is placing staff active in research in existing departments of the universities of Hull and York, so providing the infrastructure for research and critical mass for research groups. Time and the research assessment exercise, which compares research performance across UK universities, will tell how successful these arrangements are.
The innovations in the new schools may themselves be under-researched.16 Evidence is lacking for many of the changes made: for example, the outcomes of new admissions policies cannot be evaluated until the changes have been made. No substantive funding has been offered for research into the comparative outcomes of the new courses across Britain as a whole. A longitudinal cohort study to compare outcomes would be of great value, and, given the taxpayers' investment in the expansion of medical school places, this does not seem an unreasonable proposal. A comparative survey is currently in progress for the Department of Health, which includes representation from the new schools, and this may reveal further research needs.
Conclusion
The four new medical schools examined briefly here, though differing in detail, seem to be using similar approaches to key areas of medical education and have capitalised on the opportunity of development from a "clean slate." They have used evidence and current policy to modernise the selection process, the curriculum, and learning activities in accordance with the expectations of the GMC and the public and the new opportunities provided by modern information technology. Emphasis is placed on changing the "culture" of medical learning—to one that has high academic as well as vocational expectations, where the role models experienced are spread across the whole of the NHS, and where students as learners and patients as teachers are accorded higher value than in the past.
There are areas where one might predict problems. "Worst case" scenarios include a high dropout or failure rate among students from non-traditional backgrounds facing the uncertainties of unconventional curriculums; an inability of the NHS to deliver the expanded clinical placement capacity needed to underpin the expansion in medical training; inadequate academic staffing to ensure a high quality of educational development and delivery17; conflicting tensions between research and teaching in universities; and a failure to establish a credible research base. There is, however, no evidence to suggest that these scenarios are more likely to come to pass than the more positive ones envisaged in this article.
Summary points
The four new UK medical schools are implementing key reforms in medical education; they show considerable similarities in their approaches to curricular design and learning methods
Key features are integrated curriculums with patient contact throughout the course
Academic training of research methods through student options is central
Altered selection criteria is leading to a different student mix, even in non—graduate entry programmes
These four new medical schools aspire to be the pioneers of 21st century medical education, driven by the enthusiasm of local champions and the need to expand the national workforce. Their shared vision suggests a common set of educational principles, firmly grounded in best current practice but seeking to discover new routes to the goal of quality teaching and learning. The benefits should come to all—when we need the help of one of the next generation of doctors.
Since this article was written, JS has become dean at Griffith Medical School, Griffith University, Australia.
Contributors and sources: All authors contributed equally to identifying key educational issues and providing specific data from their school. AH coordinated the first drafts, with much help from all in further revisions. The sources of data are largely from the experience of the authors as senior faculty at these schools comparing their approaches to other institutions, and referencing this to the literature.
Funding: None.
Competing interests: None declared.
References
Higher Education Funding Council for England. Increasing medical student numbers in England (Report 01/31). Bristol: HEFCE, 2001.
General Medical Council. Tomorrow's doctors. London: GMC, 2003
Usherwood T, Joesbury H, Hannay D. Student directed problem based learning in general practice and public health. Med Educ 1991;25: 421-9.
Hafferty FW. Into the valley: death and the socialization of medical students. London: Yale University Press, 1991.
Silverman J, Kurtz S, Draper J. Skills for communicating with patients. Abingdon: Radcliffe Medical Press, 1998.
Asch E, Saltzberg D, Kaiser S. Reinforcement of selfdirected learning and the development of professional attitudes through peer and self assessment. Acad Med 1998;73: 575.
Sinclair S. Making doctors: an institutional apprenticeship. Oxford: Berg, 1997.
Universities UK. Social class and participation: good practice in widening access to higher education. London: UUK, 2002.
Holmes D. Eight years experience of widening access to medical education. Med Educ 2002;36: 979-84.
Australian Council for Educational Research. Graduate Australian medical schools admissions test UK: information booklet 2002-2003. Cheltenham: Universities and Colleges Admissions Service, 2002.
Harden RM, Crosby JR, Davis MH, Friedman M. Outcome-based education 5—from competency to meta-competency: a model for the specification of learning outcomes. AMEE Guide 14. Med Teach 1999;21: 546-52.
Harden RM, Stamper N. What is a spiral curriculum? Med Teach 1999;21: 141-3.
David T, Patel N, Burdett K, Rangachari P. Problem based learning in medicine. London: Royal Society of Medicine, 1999.
Van der Vleuten CPM, Verwijnen GM, Wijnen WHFW. Fifteen years of experience with progress testing in a problem-based learning curriculum. Med Teach 1996;18: 103-9.
Department for Education and Skills. The future of higher education. London: Stationery Office, 2003. (www.dfes.gov.uk/hegateway/strategy/hestrategy/pdfs/DfES-HigherEducation.pdf, accessed 5 Jul 2004).
Prideaux D, Bligh J. Research in medical education: asking the right questions. Med Educ 2002;36: 1114-5
Smith T, Sime P. A survey of clinical academic staffing levels in UK medical and dental Schools: a report to the Council for Heads of Medical Schools. London: Council for Heads of Medical Schools, 2001.(Amanda Howe, professor of)
Correspondence to: A Howe amanda.howe@uea.ac.uk
With the expansion in UK medical student numbers, four new medical schools have been established. The authors, all senior faculty members at these new schools at the time of writing, discuss how much the schools have in common in their approaches to medical education
To create more UK doctors, the government has funded an increase in medical student numbers of 57% (from 3749 to 5894)1 between 1998 and 2005. This has been done by increasing student places at existing medical schools; creating shortened programmes open to science graduates; "twinning" arrangements, which host an existing curriculum at a new site; and four entirely new schools (table 1). Through reflection on our experiences and the literature evidence, we examine to what extent these new schools have a common vision and approach to undergraduate medical education, and we discuss the rationale for and likely outcomes of these new ventures.
Table 1 Demographics of the four new UK medical schools
Key perspectives
A key aspect of a medical school's ideology is its approach to the curriculum. The UK accrediting and registering body for medicine, the General Medical Council, has for the past decade called for reforms in medical education2 and recommended courses that integrate teaching of basic sciences (anatomy, biochemistry) with clinical and social sciences, make use of community as well as hospital healthcare settings, increase overall patient contact, and provide greater student choice. New courses are likely to encourage learning methods that directly link new knowledge to patient care,3 modernise approaches to basic science (in particular anatomy4), increase emphasis on appropriate consultation skills5 and attitudinal learning,6 and promote a more humane and supportive learning environment.7
New schools also have the opportunity to take innovative approaches to selecting candidates for medical education and to the assessments that underpin the direction of student learning. How do the four new medical schools deal with these issues?
Student selection and admissions policies
The new medical schools are funded for UK and European Union applicants, and their approaches have been influenced by the "widening access" debate.8 9 They have reconsidered what constitutes necessary prior academic attainment, and they attempt to attract good candidates regardless of age and sociodemographic and school background. Interestingly, although all the new schools offer a full five year undergraduate entry course with no reduction for those who already hold a first degree, between 20% and 60% of their first cohorts have not come directly from secondary school.
All the schools claim to use selection procedures for applicants in which academic criteria are only one hurdle in the process, standardised interviews are the norm, and part of the selection rests on non-academic criteria. All have local access links and programmes to encourage applicants from non-traditional backgrounds (for example, 15% of the intake at the University of East Anglia are from access schemes whereby students from non-traditional backgrounds can do a foundation year of science preparation). The academic performance of applicants who are not coming directly from school is assessed in a variety of ways, with the Peninsula Medical School trialling the GAMSAT (graduate Australian medical schools admissions test)10 as a screening tool. Table 2 gives further details of the selection procedures.
Table 2 Admissions requirements and selection methods of the four new UK medical schools
Curriculum design
Integration
All the new schools integrate student learning by focusing on patients throughout the course. Their curriculums show no traditional divide between clinical and non-clinical phases, nor between basic and applied science. They structure learning around desired outcomes11 and systematically rehearse clinical and technical skills through simulated and supervised "near life" situations. They aim to reduce apprenticeship "tag along with me" learning, which risks wide variation in student opportunities.
All the schools provide a structured learning approach within a "spiral" curriculum (where what the student has already seen and done is explicit, and can be built on)12; this is especially valuable when learning is based on more than one campus (such as with Peninsula Medical School and Hull York Medical School) and at dispersed clinical sites. However, there are considerable differences of local detail, with each school having particular innovations in curriculum design (see table 3). These innovations may be moderated as the GMC assesses each school during its development.
Table 3 Curriculum features of the four new UK medical schools
Students in a practical skills session
Student selected modules
For students to acquire critical appraisal and research skills, the four schools have adopted repeated use throughout the course of what the GMC called student selected modules. These occupy about 30% of course time and draw on the social sciences and humanities as well as professional fields such as law and health economics. In these modules, students encounter methods and assessment modalities similar to those used in postgraduate education—such as peer presentations. All courses include a summatively assessed research project for senior students.
The options of non-clinical topics (such as humanities at University of East Anglia, Brighton and Sussex Medical School, and Hull York Medical School and community studies at Peninsula Medical School) show how these schools aim to broaden students' minds and train them for flexible application of new knowledge and perspectives to medical practice. Process goals are also embraced: Hull York Medical School uses a "market" model for students to choose their modules, to demonstrate economic principles, in line with its theme of "managing resources for quality and efficiency"—thus showing students the constraints of reliance on a "provider" market.
Fitness for purpose
Without historical constraints, the schools have designed their curriculums with the aim of creating junior doctors fit for the purpose of working as part of multidisciplinary teams that include the patients. Early patient contact, systematic consultation skills linked to clinical practice, and group learning settings are used to emphasise the responsibilities of the students towards others. Student progress is assessed on attitudinal as well as intellectual progress, thus ensuring that fitness to practise is a formative curricular goal, rather than a retrospective judgment, and enabling early diagnosis and intervention in areas of weakness (see table 4). The development of mechanisms to identify and act on concerns about fitness to practise is likely to provide other institutions with some valuable lessons.
Table 4 Methods of assessing fitness to practise in the four new UK medical schools
Learning methods and assessment
New approaches to life sciences
The basic life sciences are radically altered both in amount and approach, with dissection and laboratory work being replaced in three of the four schools by prosection (pre-dissected material displayed for students to study, examine, and touch) and use of sophisticated models and computerised imaging. The schools are most diverse in this regard, expressing their individuality and preferred philosophies through such issues as anatomy teaching, with Peninsula Medical School not using cadavers at all whereas Brighton and Sussex Medical School includes dissection throughout the course.
Patient focus is retained in theoretical learning through the use of a range of approaches to problem based learning13—"virtual patients whose problems unfold over time" (Hull York Medical School); a life cycle model tracking the stages of life through both normal and abnormal function (Peninsula Medical School); interdisciplinary clinical symposia (Brighton and Sussex Medical School); all within a systematically planned curriculum based on common clinical presentations (University of East Anglia) (see table 3).
Students engaged in small group learning
Information technology for better communication and integration
All four schools use electronic curriculum programmes ("Blackboard" or "studentcentral") to underpin and coordinate their courses. These allow rapid access to information and quick turnaround of evaluation and messaging, and allow all tutors, assessors, and students at any site to look at the curricular context of their own particular contribution. These managed learning environments form a strong backbone to self directed and e-learning.
Clinical emphasis
All the schools have adopted early contact with patients, supported by large numbers of clinical (NHS) staff as tutors in both campus based teaching and clinical placements. Although the overall time commitment to clinical placements is probably no greater than in other medical schools, they seem to be organised differently. The principle is to base learning on the patient perspective, rather than by specialty. In Hull York Medical School clinical placements, from year 1 to year 4, are fully matched to the specific systems being taught. Peninsula Medical School plans to run placements in years 3 and 4 as "pathways of care" which cross over medical specialties, and University of East Anglia uses large group teaching in general practice that matches patient contact with the "case of the week" rather than opportunistic learning. Introducing new approaches to student learning into a heavily burdened health service is a challenge for the new schools, and the feasibility of such innovations will be judged over time.
Assessment
Under the close scrutiny of panels of visitors from the GMC's Education Committee, each school has developed rigorous procedures to assess students' knowledge, skills, attitudes, and fitness to practise. Formative assessment is generally used to enable students to appreciate their progress, while summative tests ensure that only those who are performing adequately can progress to the next stage of the course or to their preregistration year. Peninsula Medical School has adopted a progress test (run four times a year) for its major summative assessment of applied medical knowledge.14 The objective structured clinical (and practical) examination (OSCE or OSCPE) is commonly used to assess clinical skills; projects and presentations are used to assess other academic ability; and portfolios of evidence from students and tutors reveal attitudes and behaviour. Peer and tutor feedback and reflection on experiential learning help students to compile a summatively assessed "portfolio report." The time needed to perform and validate such detailed, multi-faceted assessments may prove challenging as student numbers increase over the first five years, and more so if further expansion occurs.
The wider academic context
There is considerable tension between teaching and research roles in most universities,15 and this is particularly acute for the new schools—where staff numbers are still building up, there are major educational and organisational challenges in setting up the new courses, and the research units have no institutional track record. Peninsula Medical School has developed research institutions rather than traditional clinical academic departments as the main "home" for its staff, sending a strong message about the value of education in a research-rich environment. Hull York Medical School is placing staff active in research in existing departments of the universities of Hull and York, so providing the infrastructure for research and critical mass for research groups. Time and the research assessment exercise, which compares research performance across UK universities, will tell how successful these arrangements are.
The innovations in the new schools may themselves be under-researched.16 Evidence is lacking for many of the changes made: for example, the outcomes of new admissions policies cannot be evaluated until the changes have been made. No substantive funding has been offered for research into the comparative outcomes of the new courses across Britain as a whole. A longitudinal cohort study to compare outcomes would be of great value, and, given the taxpayers' investment in the expansion of medical school places, this does not seem an unreasonable proposal. A comparative survey is currently in progress for the Department of Health, which includes representation from the new schools, and this may reveal further research needs.
Conclusion
The four new medical schools examined briefly here, though differing in detail, seem to be using similar approaches to key areas of medical education and have capitalised on the opportunity of development from a "clean slate." They have used evidence and current policy to modernise the selection process, the curriculum, and learning activities in accordance with the expectations of the GMC and the public and the new opportunities provided by modern information technology. Emphasis is placed on changing the "culture" of medical learning—to one that has high academic as well as vocational expectations, where the role models experienced are spread across the whole of the NHS, and where students as learners and patients as teachers are accorded higher value than in the past.
There are areas where one might predict problems. "Worst case" scenarios include a high dropout or failure rate among students from non-traditional backgrounds facing the uncertainties of unconventional curriculums; an inability of the NHS to deliver the expanded clinical placement capacity needed to underpin the expansion in medical training; inadequate academic staffing to ensure a high quality of educational development and delivery17; conflicting tensions between research and teaching in universities; and a failure to establish a credible research base. There is, however, no evidence to suggest that these scenarios are more likely to come to pass than the more positive ones envisaged in this article.
Summary points
The four new UK medical schools are implementing key reforms in medical education; they show considerable similarities in their approaches to curricular design and learning methods
Key features are integrated curriculums with patient contact throughout the course
Academic training of research methods through student options is central
Altered selection criteria is leading to a different student mix, even in non—graduate entry programmes
These four new medical schools aspire to be the pioneers of 21st century medical education, driven by the enthusiasm of local champions and the need to expand the national workforce. Their shared vision suggests a common set of educational principles, firmly grounded in best current practice but seeking to discover new routes to the goal of quality teaching and learning. The benefits should come to all—when we need the help of one of the next generation of doctors.
Since this article was written, JS has become dean at Griffith Medical School, Griffith University, Australia.
Contributors and sources: All authors contributed equally to identifying key educational issues and providing specific data from their school. AH coordinated the first drafts, with much help from all in further revisions. The sources of data are largely from the experience of the authors as senior faculty at these schools comparing their approaches to other institutions, and referencing this to the literature.
Funding: None.
Competing interests: None declared.
References
Higher Education Funding Council for England. Increasing medical student numbers in England (Report 01/31). Bristol: HEFCE, 2001.
General Medical Council. Tomorrow's doctors. London: GMC, 2003
Usherwood T, Joesbury H, Hannay D. Student directed problem based learning in general practice and public health. Med Educ 1991;25: 421-9.
Hafferty FW. Into the valley: death and the socialization of medical students. London: Yale University Press, 1991.
Silverman J, Kurtz S, Draper J. Skills for communicating with patients. Abingdon: Radcliffe Medical Press, 1998.
Asch E, Saltzberg D, Kaiser S. Reinforcement of selfdirected learning and the development of professional attitudes through peer and self assessment. Acad Med 1998;73: 575.
Sinclair S. Making doctors: an institutional apprenticeship. Oxford: Berg, 1997.
Universities UK. Social class and participation: good practice in widening access to higher education. London: UUK, 2002.
Holmes D. Eight years experience of widening access to medical education. Med Educ 2002;36: 979-84.
Australian Council for Educational Research. Graduate Australian medical schools admissions test UK: information booklet 2002-2003. Cheltenham: Universities and Colleges Admissions Service, 2002.
Harden RM, Crosby JR, Davis MH, Friedman M. Outcome-based education 5—from competency to meta-competency: a model for the specification of learning outcomes. AMEE Guide 14. Med Teach 1999;21: 546-52.
Harden RM, Stamper N. What is a spiral curriculum? Med Teach 1999;21: 141-3.
David T, Patel N, Burdett K, Rangachari P. Problem based learning in medicine. London: Royal Society of Medicine, 1999.
Van der Vleuten CPM, Verwijnen GM, Wijnen WHFW. Fifteen years of experience with progress testing in a problem-based learning curriculum. Med Teach 1996;18: 103-9.
Department for Education and Skills. The future of higher education. London: Stationery Office, 2003. (www.dfes.gov.uk/hegateway/strategy/hestrategy/pdfs/DfES-HigherEducation.pdf, accessed 5 Jul 2004).
Prideaux D, Bligh J. Research in medical education: asking the right questions. Med Educ 2002;36: 1114-5
Smith T, Sime P. A survey of clinical academic staffing levels in UK medical and dental Schools: a report to the Council for Heads of Medical Schools. London: Council for Heads of Medical Schools, 2001.(Amanda Howe, professor of)